The DSM Diagnostic Criteria for Sexual Masochism

I reviewed the empirical literature for 1900–2008 on the paraphilia of Sexual Masochism for the Sexual and Gender Identity Disorders Work Group for the for the coming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The results of this review were tabulated into a general summary of the criticisms relevant to the DSM diagnosis of Sexual Masochism, the assessment of Sexual Masochism utilizing the DSM in samples drawn from forensic populations, and the assessment of Sexual Masochism using the DSM in nonforensic populations. I concluded that the diagnosis of Sexual Masochism should be retained, that minimal modifications of the wording of this diagnosis were warranted, and that there was a need for the development of dimensional and structured diagnostic instruments. It should be noted that this summary reflects my original literature review. Subsequently, interactions with other members of the workgroup and advisors have resulted in modification of these initial suggestions.

DSM, the existent studies that have offered critiques relevant to the diagnosis of Sexual Masochism, and the few studies that have used criteria from the DSM in both forensic and not clearly forensic populations. It will review other information obtained from community samples and then offer recommendations for the diagnostic criteria for DSM-V. Further, for ease of reference, several tables have been developed. Table 1 contains criticisms relevant to Sexual Masochism, Table 2 lists studies that have utilized DSM-criteria on Sexual Masochism in exclusively forensic populations, and Table 3 contains studies that have been done using the DSM on mixed (consisting of both forensic and non-forensic) populations. Finally, an appendix listing all of the previous DSM criteria sets for SexualMasochism (Appendix 1), along with ICD-9 (World Health Organization, 1989) and ICD-10 criteria (World Health Organization, 1992), and ICD-10 research criteria (World Health Organization, 1993) for sadomasochism are appended (Appendix 2). (Tables are found in this PDF)

Method

Consisted of a literature search by the librarian of theNew York State Psychiatric Institute using the search terms of ‘‘sexual masochism,’’ ‘‘sexual sadism,’’ ‘‘sadomasochism,’’ ‘‘domination,’’ ‘‘bondage,’’‘‘BDSM,’’‘‘perversion,’’‘‘paraphilia,’’‘‘sexual homicide,’’‘‘ sexual murder,’’‘‘lust murder,’’ and ‘‘sex killer’’of PubMed from 1966 through December 15, 2008, and of Psych Info from 1900 through December 15, 2008. Additionally, all of the prior Diagnostic and Statistical Manuals were consulted as well as ICD-9 and ICD-10. Articles were culled and attention was focused on articles using the DSM to make diagnoses of Sexual Masochism or offering critiques of the diagnostic criteria for SexualMasochism or the paraphilias. Discussion of this literature and the diagnostic criteria was engaged in with colleagues.

Results

Summary of Evolution of Diagnostic Criteria for Sexual Masochism in the DSM

Masochism was not mentioned in DSM-I (American Psychiatric Association, 1952). It was added to DSM-II for use in the United States only (American Psychiatric Association, 1968) (Appendix 1).

It was continued in DSM-III (American Psychiatric Association, 1980), where this diagnosis was made with either of the items: ‘‘(1) A preferred or exclusive mode of producing sexual excitement is to be humiliated, bound, beaten, or otherwise made to suffer, or (2) The individual has intentionally participated in an activity in which he or she was physically harmed or his or her life was threatened’’(p. 274). Thus, an individual could have been diagnosed with this disorder only for participating in such activity with a consensual partner, if this was preferred or exclusive.

DSM-III-R (American Psychiatric Association, 1987) changed to require two criteria:‘‘A. Over a period of at least six months, recurrent, intense sexual urges and sexually arousing fantasies involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.’’ And ‘‘B. The person has acted on these urges, or is markedly distressed by them.’’ Here again, the occurrence of such urges or fantasies in an individual who was practicing S & M with a consensual partner was in itself considered pathological, providing substance to the claims by S&M practitioners that their particular behavior had been selected out as being pathological per se.

In DSM-IV (American Psychiatric Association, 1994), the A criterion was continued, substantially unchanged: ‘‘A. Over a period of at least 6months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.’’ And the B criterion, as with the other paraphilias, was modified to incorporate elements of subjective distress or dysfunction: ‘‘B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.’’ Finally, DSM-IV-TR (American Psychiatric Association, 2000) made no changes in the criteria.

Review of Criticisms Relevant to Sexual Masochism

Many criticisms relevant to Sexual Sadism are also relevant to Sexual Masochism, and are contained in Table 1 and will not be repeated here (see Krueger, 2009). Generally, these indicate, among many concerns, that the paraphilias, or sadomasochism, should not be included in the DSM because they are not mental disorders, they are unscientific, they are unnecessary, and to do so pathologizes groups who engage in alternative sexual practices.

Indeed, Baumeister and Butler (1997) entitled their chapter in the edited volume Sexual Deviance as ‘‘Sexual Masochism: Deviance without Pathology,’’ emphasizing that it was not pathological. In a recent chapter on Sexual Masochism, Hucker (2008) reviewed the literature. He wrote, addressing the call to remove the paraphilias from the DSM:

On the other hand, the fact that a minority of sadomasochists do present with serious injuries or die during their activities (Agnew, 1986; Hucker, 1985) should make us consider seriously whether removing these behaviors from the domain of mental disorders is wise at the present time, especially as there is much room for more research on the topic. Kurt Freund (Freund, 1976) applied the term ‘‘dangerous’’ to the more extreme forms of sadism and masochism, and it would seem prudent at this stage in our knowledge to continue to refer to these more extreme cases by such a term, thereby distinguishing them from the more benign manifestations (‘‘mild’’ masochism or erotic submissiveness) of what may well be a continuum of behaviors that merges with ‘‘normal’’ sexual expression. (pp. 260–261)

Review of Diagnostic Studies in Forensic Populations

Only three studies mention the diagnosis of Sexual Masochism based on the DSM in studies of forensic populations and these do not indicate a high occurrence of this diagnosis. In a study of 45 males with pedophilia using an unvalidated structured clinical interview for the sexual disorders, Raymond, Coleman, Ohlerking, Christenson, and Miner (1999) found that no subjects met criteria for sexual masochism, despite the discovery of numerous other paraphilias, in addition to pedophilia.

Becker, Stinson, Tromp, and Messer (2003) reported on a review of the legal files of 120 sexual offenders who were petitioned for civil commitment in Arizona. A total of 8.5% received a diagnosis of sexual sadism and only 2% sexual masochism.

Hill, Habermann, Berner, and Briken (2006) examined court reports on 166 men who had committed a sexual homicide in Germany. Psychiatric disorders were diagnosed by the raters according to DSM-IV. Sixty-one men (36.7%) received a diagnosis of Sexual Sadism, 5.4%. received a diagnosis of Sexual Masochism, and 14.8% of those with Sexual Sadism also had Sexual Masochism. Structured diagnostic instruments were used to make diagnoses of personality disorders, but not for the paraphilic disorders.

To summarize, only three studies have been conducted on forensic populations that mention Sexual Masochism diagnosed by the DSM, compared with a substantial volume of studies examining for Sexual Sadism. One of these studies reported no Sexual Sadism in a group of 45 males with pedophilia, one an occurrence of 2% out of 120 civilly committed sexual offenders, and one 5.4% in a group of 166 men who had committed a sexual homicide. In this group, 14.8% of men who had Sexual Sadism also had Sexual Masochism. It is also not clear to what extent sexual masochism was contributory to any criminal behavior in these studies. Only one of these studies used structured diagnostic instruments to assess for paraphilic disorders.

Review of Diagnostic Studies in Non-Forensic Populations

Abel, Becker, Cunningham-Rather, Mittelman, and Rouleau (1988) and Abel et al. (1987) reported on an outpatient population of 561 men seeking voluntary evaluation and treatment for possible paraphilias in Memphis, Tennessee or in New York City. In the Memphis sample, all categories of paraphilias were evaluated; in the NewYork sample, mostly subjects with a diagnosis of rape or child molestation were seen. DSM-II and DSM III criteria were used, with all subjects reporting recurrent, repetitive urges to carry out deviant sexual behaviors. Subjects were not included in the research solely because they had committed the paraphilic behavior. One-third of this sample was referred from legal or forensic sources, one-third from mental health sources, and one-third from other sources. Of these, 28 men were diagnosed with sadism and 17 with masochism. These disorders had occurred in the patient during his lifetime, and there was no indication as to which, if any, paraphilia was a focus of concern.

Kafka and Prentky (1994) collected data prospectively on 63 consecutively evaluated outpatient males. Three men were excluded. Thirty-four were seeking treatment for paraphilic disorders and 26 for paraphilia-related disorders. A questionnaire was used along with a structured interview to establish a diagnosis, which represented a lifetime diagnosis. It was not clear which paraphilia was the focus for treatment. Twelve percent of the paraphilic group was diagnosed with sadism and 9% with masochism. Kafka and Prentky recommended that future studies should utilize structured diagnostic interviews and blind interviewing techniques.

The American Psychiatric Association (1999) in a book called Dangerous Sex Offenders reported on somedata given as a personal communication from Dr. Gene Abel on a sample of 2,129 patients evaluated at 140 sexual treatment clinics in North America, who presumably answered questions on the Abel Assessment of Sexual Interest (Fischer, 2000), although this was not explicitly stated. In this sample, 2.3 percent reported they had engaged in sadism and 2.5% in masochism, but the methods and criteria used to obtain this information were not described.

Kafka and Hennen (2002, 2003) reported on a population of 120 consecutively evaluated outpatient males with paraphilias (N=88, including 60 sex offenders) or paraphilia-related disorders (N=32). Structured interviews and DSM-IV criteria were used to make lifetime diagnoses. Eleven percent of the paraphilic sample had Sexual Masochism and 5% Sexual Sadism. They noted that there were no rating instruments with documented reliability and validity available to diagnose both paraphilias and paraphilia-related disorders. The index paraphilia for which treatment was sought was not specified.

The above four studies were the only ones I have found which apply DSM criteria for Sexual Masochism to populations that were not exclusively forensic, and at least three of these had a substantial component of forensic cases. This implies that researchers are not using criteria from the DSM to conduct research on Sexual Masochism and/or that individuals with Sexual Masochism are not presenting for treatment.

Review of Studies of Masochistic Behavior in the Community, in Treatment Populations, and with Regard to Harm

Incidence of Masochistic Behavior in the Community

Moser and Levitt (1987) reported that general population surveys had not established the proportion of the general population that identified as S/M and noted that it was not clear if any specific behaviors could be classified as S/M specifically.However, S & M behavior appears to be fairly common. Kinsey, Pomeroy, Martin, and Gebhard (1953, p. 678) reported that 26% of females and 26% of males reported a definite and/or frequent erotic response to being bitten. Hunt (1974), in a survey of sexual behavior in the United States involving 2,026 respondents in 26 cities, found that 4.8% of males and 2.1% of females reported ever having obtained sexual pleasure from inflicting pain, and 2.5% of males and 4.6% of females from receiving pain. A recent Australian study (Richters, Grulich, De Visser, Smith, & Rissel, 2003) utilizing a large telephone survey reported that 2.0% of men and 1.4% of women reported that in the preceding 12 months they had been involved in bondage and discipline, sadomasochism, or dominance and submission. In another article, Richters, De Visser, Rissel, Grulich, and Smith (2008) concluded that BDSM (referring to bondage and discipline, ‘‘sadomasochism’’ or dominance and submission) was simply a sexual interest and not a pathological symptom of past abuse or of difficulty with ‘‘normal sex.’’

Cre´pault and Couture (1980), using a semistructured interview and a self-administered questionnaire, reported on the erotic fantasies of 94 men occurring during heterosexual activity; 11.7% reported that they had had a fantasy of being humiliated, and 5.3% where they were beaten up. A recent systematic review of the research literature on women’s rape fantasies (Critelli & Bivona, 2008) reported that between 31 and 57% of women had fantasies in which they were forced into sex against their will and that for 9–17% of women these were a frequent or favorite fantasy experience.

Thus, although there is not a lot of survey information on sexual masochistic or sadomasochistic behavior, it has been reported in from 1 to 5% of the U.S. and Australian population. Sadomasochistic sexual fantasies during sexual intercourse were reported by 10% of men in a Canadian study and a large percentage of females (from 31 to 57%) were reported to have rape fantasies in a recent review of the literature.

Presentation of Patients with Sadomasochism or Masochism for Treatment

Freund, Seto, and Kuban (1995) reported on a group of 54 male masochists seen at their sexology clinic. They reported that masochistic patients appeared to be relatively rarely seen in a sexology clinic and that, in contrast to individuals who had presented for treatment of other paraphilias, their masochistic patients were predominately self-referred and rarely got into legal trouble because of their paraphilia. Spengler (1977, 1983), in a survey of 245 manifestly sadomasochistic West German men, reported that 20% rejected their sadomasochistic orientation, 70% accepted it, and 9% ‘‘didn’t know. ’’ Ninety percent had never visited a doctor, psychiatrist, or psychologist because of their sadomasochistic deviation, but 10% reported doing this at least once. Moser and Levitt (1987) reported on the results of a questionnaire given to 178 men self defined as S&M. Most respondents were satisfied with the S&M part of their sexuality, but 6% expressed distress concerning their behavior and 16% had sought help from a therapist for their S & M desires. Thus, according to the above studies, patients with Sexual Masochism infrequently see mental health professionals for concerns about this behavior.

Is There Evidence of Harm from Sadomasochistic or Masochistic Behavior?

Most studies of individuals practicing sadomasochism in the community have shown evidence of good psychological and social function, as measured by higher educational level, income, and occupational status compared with the general population (Breslow, Evans, & Langley, 1985; Moser & Levitt, 1987; Sandnabba, Santtila, & Nordling, 1999; Santtila, Sandnabba, & Nordling, 2000). Weinberg (2006) concluded his review of the social and psychological literature by saying that ‘‘…sociological and social psychological studies see SM practitioners as emotionally and psychologically well balanced, generally comfortable with their sexual orientation, and socially well adjusted’’( p. 37). A recent study by Sagarin, Cutler, Cuther, Lawler- Sagarin, and Matuszewich (2009) examining hormone levels and psychological measures of relationship closeness in subjects before and after participating in sadomasochistic activities reported reductions in physiological stress as measured by cortisol and increases in relationship closeness among participants who reported their SM activities went well.

Studies of survivors of this practice indicate that nearly all individuals fantasize about masochistic scenarios as they engage in it (Hucker, 2008). Fifty fatalities yearly from this activity are reported in the United States (Litman & Swearingen, 1972) and case reports of death from electrocution during other autoerotic procedures exist (Cairns, 1981).

Thus, studies which have been done show generally good psychological and social functioning compared with the general population and that sadomasochistic activity may be associated with reductions in physiological stress and increase in relationship closeness. There are, however, case reports of injury or death associated with masochistic activity, and evidence that most individuals who engage in or die during erotic or autoerotic asphyxiation have masochistic fantasies.

Misuse of DSM in Child Custody Proceedings and Discrimination

Klein and Moser (2006) described the case of the misuse by forensic professionals of the DSM criteria in a child custody suit, suggesting that these not infrequent cases should be an impetus to the editors of the DSM to reevaluate its classification of atypical sexual behavior as pathological and to strengthen its warnings against misuse. Wright (2006) presented information on violence and discrimination against SM-identified individuals; of 1017 SM individuals surveyed, 36% had suffered some sort of violence or harassment because of their SM practices, and 30% had been victims of job discrimination. Hypoxyphilia The DSM-V paraphilias workgroup discussed this entity and decided, because of the dangerousness of this activity and its appearance as a clinical syndrome, that this might merit inclusion as a separate paraphilic disorder. An advisor to the subworkgroup has prepared an analysis of the literature (Hucker, 2009). Hucker recommended the use of the term ‘‘asphyxiophilia’’ given the observation that it appeared that individuals engaging in this behavior primarily obtained sexual arousal through restriction of breathing rather than the subjective experience of oxygen lack. He also recommended keeping this diagnosis under the general rubric of Sexual Masochism. Relationship and Cultural Context Mitchell and Graham (2008) raised the issue that relationship influences are not considered in the diagnosis of sexual disorders and Tiefer (2004) and Tiefer, Brick, and Kaplan (2003) noted that both relationship and cultural context are important in assessing and treating sexual disorders. Given that Sexual Masochism is one of the paraphilias that could occur in the context of a relationship (along with Transvestic Fetishism, and perhaps some of the other unnamed paraphilias), it might make sense to consider adding a specification as to whether Sexual Masochism occurred in the context of a relationship.

Recommendations and Discussion

Should Sexual Masochism Be Retained in the DSM?
Yes, for the following reasons:

1. While masochistic and/or sadomasochistic behavior occur with some frequency in the population and is associated with generally good psychological or social functioning, there are a very small number of cases where masochistic fantasy and behavior result in severe harm or even death. These cases clearly indicate a sexual interest pattern that has become pathological. Since so little is know about this behavior, further research is indicated, and inclusion in the DSM would facilitate this.

2. Although there are only a small number of studies that report on the occurrence of sexual masochism in forensic populations, one of these (Hill et al., 2006) reported that, of 166 sexual murderers, 5.4% received a diagnosis of sexual masochism, and 14.8% of those with sexual sadism also had sexual masochism. Further, because of the association of sadism with masochism, and because the studies of forensic populations did not use structured diagnostic inventories, the occurrence of sexual masochism in forensic populations could be substantially higher. In my opinion, retention of the diagnosis of Sexual Masochism in the DSM would allow for further research to be done on Sexual Masochism in forensic populations.

3. The current criteria for Sexual Masochism in the DSM do not apply to the vast majority of individuals who are practicing this behavior. There clearly are some individuals who present for treatment for Sexual Masochism, where such behavior has become out of control and a source of distress or dysfunction, and the current diagnostic criteria are appropriate for these individuals.

4. Some of the concerns of those in the S & M community regarding the misuse of the DSM to diagnose them could be addressed by strengthening caveats circumscribing the application of the DSM in clinical or in forensic matters, particularly as regards S & M.

Should There Be Any Change in the Diagnostic Criteria?

Yes. Please see Table 4 (found in PDF) for the change I am recommending and the reason for it. Otherwise, I think that the current criteria do a good job of defining Sexual Masochism that has become pathological and should not be changed. Further, the paraphilias subgroup will be discussing dimensional assessment, and this may afford the opportunity to depict Sexual Masochism on some continuum, or to qualify this disorder as mild, moderate, severe, or extreme.